America Has World’s Third-Worst Level of Health Inequality

A new paper from Harvard health-policy researchers has some disheartening news: the US leads the world in health inequality. Of the 32 nations studied, only two were worse than the US.
The study, recently published in Health Affairs, examined attitudes towards health and health care in 32 middle and high-income nations from 2011 to 2013. Regardless of country, high-income individuals were generally more positive about their health and health care than low-income respondents. Only two countries, Japan and Switzerland, had citizens who were equally healthy.
38.2 percent of Americans with incomes under $22,500 a year reported fair or poor health. However, only 12.3 percent of Americans making over $47,700 per year gave the same answer. Only Chile and Portugal were worse than the US on this measure.

In addition to describing their health, respondents reported on their past experiences as well as their confidence about accessing health care in the future.
Around the world, low-income respondents were less confident that they would be able to get needed treatment in the future. Bulgaria, Chile, and the US had the highest disparities on this measure. That lack of confidence clearly correlated to low-income people forgoing health care because of cost.

The US ranked second in the disparity between rich and poor skipping health care, right behind the Philippines. 20 percent of poor American respondents were unable to access treatment due to cost, compared to only 4 percent of rich Americans.

Even when low-income Americans could access health care, they were more likely than high-income respondents to report dissatisfaction with the quality of care.

One of the more surprising findings reveals that US citizens are very aware of this disparity. Two-thirds of American respondents agreed that many people couldn’t access the health care they need, higher than any other country. However, Americans were shockingly unperturbed by this knowledge.

The study revealed that “ethical concerns about the fairness of income-based health-care disparities were less common in the United States than in most of the other countries in our sample.” Over half of the Americans surveyed felt than income-based health inequality was unfair, but were still less likely than their global counterparts to feel moral discomfort.

An important consideration of the study is its timing. US respondents were surveyed in 2012, Obama’s Affordable Care Act was enacted. The ACA’s overhaul of the insurance market resulted in Medicaid coverage for an additional 15 million low-income Americans.

Taking this development into account, the study’s authors adjusted for insurance status in their cross-country comparisons. However, the adjustments only minimally affected health disparities. It is likely, then, that income-based health inequality hasn’t greatly improved in the years since ACA was implemented.

Still, Obamacare was a major step in the right direction, as it sought to address health inequality. As Congress weighs repealing and replacing the ACA and cutting Medicaid, the authors caution that an ACA replacement needs to address the rampant income-based disparity.
The currently proposed replacement, the American Health Care Act, would result in rising premiums and out-of-pocket expenses for low-income Americans. Insurers would also be able to drop coverage for some conditions. Ultimately, the policy would result in many Americans losing health insurance.

Harvard’s health policy researchers are shaking their heads at the proposition. A return to the pre-Obamacare healthcare system would only exacerbate health inequality.